Begin when ready!

(14 Questions)

This Lifestyle Questionnaire is designed to help you uncover potential blind spots to your health. As a thank you, we'll provide you a digital copy of Preventing Decline - Move with Purpose book or a way to request a physical copy if you prefer.

First Name

Last Name

Phone *

Email *

Address

Street Address

City

State

Country

Postal code

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1. Do you perform strength training exercises (with weights, such as dumbbells for example) for at least 30 minutes, 2x per week on a consistent basis?

Yes

2. Do you perform flexibility stretches to improve your mobility (for example, yoga or stretches where you “hold” a position) for at least 15 minutes, 5x per week on a consistent basis?

Yes

3. Do you safely challenge your balance by performing various stabilization exercises (for example, standing on one foot) for at least 5 minutes, 3x per week on a consistent basis?

Yes

4. Do you have Hearing Loss or difficulty hearing in noise?

Yes

5. Have you been experiencing increasing 'Senior Moments' or Memory Concerns?

Yes

6. Do you have Tinnitus or ringing in the ears?

Yes

7. Have your recently fallen or have a fear of falling?

Yes

8. Do you average at least 7 hours of sleep most nights? (At least 6 nights/per week)

Yes

9. Do you feel rested when you wake up most mornings? (At least 6 nights/per week)

Yes

10. Do you feel you are at a healthy weight?

Yes

11. Do you strive to eat as healthy as you know how to, at least 80% of the time?

Yes

12. Do you commonly pursue continual learning opportunities? (i.e. you have a hobby, read books daily, take continual education classes, etc.)

Yes

13. Are you a part of a community (religious, service volunteer, etc.) and connect with others face to face at least 3-4x week?

Yes

14. Do you practice Mindfulness (i.e. take extended periods of time to be silent, do mindful breathing, pray, etc.) at least 4-5x week?

Yes

Thank you for completing the Questionnaire!

You can access the book Preventing Decline: Move with Purpose by Downloading the free Preventing Decline App from either the App Store (iPhone) or the Google Play Store (Android).

If you prefer a free physical copy to be mailed to you for free (minus shipping & handling) use coupon code PURPOSE at checkout at our online store.

We look forward to helping you add life to your years!